For critical or long-term ventilator dependent patients, tracheostomy is always vital to them. Moreover, tracheostomy can help patients to maintain better airway hygiene and to decrease dead space in the breathing tube. As a result, tracheostomy plays an important role in the field of critical or long-term care. In Europe or American area, experts suggest tracheostomy should be early established in patients who cannot maintain their airway or patients who have depended on ventilator more than one week and cannot weaned from ventilator soon (Durbin, Respir Care. 2010 August; 55(8):1056-68; Mallick et al., Eur J Anaesthesiol. 2010 August; 27(8):676-82; and 2) Dempsey et al., Br J Anaesth. 2010 December; 105(6):782-8).
Traditionally tracheostomy is completed on a patient under general anesthesia in an operation room. Surgeons incise transversely then dissect over the lower neck. After seeing the 2nd or 3rd trachea ring visibly, they incise the trachea. Then tracheostomy tube is placed into the incision. The patients should be transferred from intensive care units (ICU) or wards to operation rooms. The process of transferring requires the manpower of medical personnel and increases many potential risks. Moreover, many patients are supported with continuous vital drugs such as inotropes or vasopressors, and continuous invasive monitors are necessary for them. The transferring risk and difficulty may largely increase in such situation.
The general procedures of “percutaneous dilatational tracheostomy (PDT)” are described as below. After surface locating the surgical area, the surgeon incises 1.5 to 2 cm wound. Then the bronchoscope is inserted into the patient's previous placed endotracheal tube. When the bronchoscope is placed over the tip of endotracheal tube, the endotracheal tube and bronchoscope will be withdrawn slowly. After the light of bronchoscope pass the incision wound, the surgeon will see the light emitted from bronchoscope over the incision area. Subsequently, under bronchoscope examination and guidance, the surgeon tries to locate and puncture. When the puncture advances the trachea, guiding wire is placed. Later, the special dilatational instruments are used in turn for dilating subcutaneous tissue and anterior trachea wall.
In Taipei Veterans General Hospital, we have developed percutaneous dilatational tracheostomy (PDT) for more than a decade. At present we complete most PDT at bedside in the intensive care units. When the patients are under intravenous general anesthesia, both anesthesiologists and chest surgeons cooperate to do this invasive operation. Anesthesiologists are responsible for bronchoscope examination and guidance. On the other hand, chest surgeons are responsible for puncture and tracheostomy creation. In our medical center, about one third tracheostomy operations were done by this at bedside PDT technique. Through this method we can decrease the transferring risks and enhance patient safety. Further, we can make the medical resource application and operation room usage more efficiently.
In our experience, the most critical and danger step of PDT is how to proper puncture the needle into trachea. Traditionally we use instrument lightly compress trachea wall then we can locate the puncture site according to the change due to trachea compression under bronchoscopy. If there is any deviation of puncture, this may cause damage to the neighboring tissue such as thyroid gland or blood vessels. In addition, if the puncture angle or direction is not good, that may lead to the difficulty of the guiding wire placement or impossibility to observe the process of puncture under bronchoscopy. Moreover, it may lead to the puncture to bronchoscope then cause the damage to bronchoscope. All above conditions will prolong surgical time, or increase the puncture times, or cause the endotracheal tube dislodgement. The chance of such difficult operation or complications is related to the patient's airway anatomy, duration of endotracheal tube placement, skill and experience of the operator, and communication between the bronchoscope examiner and the operator. In a word, the traditional method tends to cause the above-mentioned complications. Accordingly, the present invention is to provide a device and a method for more accurate and safer guidance, locating, and puncture.